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Raising I.Q. in Toddlers With Autism

A new intensive program for very young children with autism has produced impressive results, leading to substantial gains in I.Q. and in listening skills after two years of therapy.

The program, called the Early Start Denver Model, or E.S.D.M., was part of a two-year study of 48 children as young as 18 months old. Half the children received the intensive therapy, while the rest received a community-based autism intervention, according to a report in the journal Pediatrics.

While children in both groups improved, the gains were greater in the Early Start program. At the conclusion of the study, the I.Q.’s of children who took part in the E.S.D.M. program had improved by about 18 points, compared with a 4 point improvement in the other group. Children in the treatment group also posted bigger gains in listening and comprehension skills. For seven of the children in the treatment group, the improvements were pronounced enough to warrant a change in diagnosis from autism to a milder condition, whereas only one child in the community-based intervention group was given a less severe diagnosis.

I recently spoke with Dr. Rogers to learn more about the E.S.D.M. program. Here is our conversation.

Q.

How is this intervention different from the kinds of community-based programs typically offered to children with autism?

Sally J. Rogers, Ph.D.

A.

First, the kids are really young. Another important fact is that the kind of intervention that is being used is different. This is a developmentally based intervention that really pays a lot of attention to the quality of relationships. It’s a playful interactive kind of intervention. Other interventions are more didactic or adult instructional. This is the first time a play-based interactive model has been tested and found to be successful.

Q.

When a parent hears that more interaction might help a child with autism, they worry they are being blamed for not interacting enough with their child. How do you answer those fears?

A.

One of the things I always say when I start to talk about this is that parents of children with autism are very good at interacting with their child. It’s the children with autism who are not good at interacting. What can happen is when the children aren’t giving parents cues that they’re on the right track, the parents don’t know to continue. They think that if the children aren’t responding, they, the parents, are not doing something right.

With this kind of intervention, we really turn up the social volume. We teach parents to give really clear clues and to look for these really subtle signs that the children are enjoying what’s going on. We teach the parents how to maximize getting their message in and being aware of what’s happening.

Q.

But doesn’t autism make it difficult for a parent or teacher to engage with a child?

A.

Autism is a disorder that really removes children from social interaction. What we’re doing is getting the social messages into the children in a very focused way. Many people think children with autism aren’t aware of other people or don’t enjoy social interaction, so you have to do other things to teach them.

That’s an important thing about this study. It’s showing that children with autism respond to playful interactions from people they like or people they love, and they learn from that just like typically developing children do. That’s an important message. When you learn how to embed teaching in playful interaction, these children enjoy it too and learn from it.

Q.

Can you explain how the new treatment is different from traditional methods used to teach children with autism?

A.

Sure. A traditional way might be to say the word “ball.” The child is sitting at the table, and the adult holds the ball and says: “Say ball. Say ball.” If the child makes a sound that’s kind of like ball, they hand them an M&M or juice or a cracker. They do it again. “Say ball.” They want the child to say it a little more clearly. If they do, the child receives a reinforcement. If not, the ball goes away for a minute. If the child says something like “ba,” they get the reward.

Q.

So how would you teach a child using this new method?

A.

In this interaction, there might be a little boy in a playroom with an adult. There’s a bucket of balls, and the adult is on the floor. The boy picks up a ball, and the therapist picks up a ball. The therapist empties out the bucket. Then she throws her ball into the bucket and says “ball.” He watches and throws. She says “ball” again. She reaches in and picks up the ball and says, “Do you want ball?” And she says, “ball,” and hands it to him. She picks up another ball and throws it into the bucket.

Each time he says something, she gives him the ball. The two are playing a game of throwing balls in a bucket. They throw to each other. They might be bouncing the balls. There is a lot of variation going on. The therapist is using the child’s interest to get him focused on saying the word. Having the ball is a reward for making sounds. She’s also working on throwing skills.

All of this is going on while they are smiling and having a good time, rolling it back and forth, practicing social play and turn taking. In this episode, you see the child has lots of learning activities. It’s the same thing the other child is learning, but now he’s doing it in a more meaningful way. He’s motivated to have it and say it. It’s a rich learning situation that’s a lot of fun and motivated by a child’s pleasure.

Q.

But what if a parent says his or her child simply isn’t interested in the ball?

A.

Find the smiles. We start by finding something that child enjoys — something that makes that child smile, that makes him want to do it again. We start that activity, and he starts to participate. Then that child is going to give a cue that he wants it to go on again. It might be a look, a whine, a noise. The child has communicated he wants more. That’s how we start. We develop these play routines that children love and give children the sense they have control over them.

Q.

How is this different from what parents might do themselves?

A.

Lots of times the parent will roll a ball to a child, and a child is not interested, and the parent feels like they’ve failed. They haven’t failed. It’s hard to get the attention of a young child with autism. It’s hard to build their motivation for things. It’s just a different way of interacting. When you’re talking about children as young as 18 months, it’s not easy to get a toddler sitting at a table quietly while you give them lessons. This was an approach to really capitalize on their own interests and the environment.

Q.

How much treatment did the control group receive?

A.

It was a randomized study, so children were assigned to one or the other. The children in the comparison group got an intervention in a community setting. They received evaluations and diagnoses and were referred to community providers where the children got speech therapy, occupational therapy. The children in the other group got an intervention and quite a bit of it. The comparison children got 18.5 hours a week of intervention over the two years of study. The group receiving this model got 22 hours a week of intervention. The groups aren’t that different in number of hours.

Q.

How meaningful are the gains documented in this study, particularly the increase in I.Q.?

A.

Every child in this study made progress. Children in lots of different interventions make progress. What we’re trying to do is close the gap. Often there is a gap between where they are and where their peers are. We’ve got to accelerate their development. When you see a change in scores like this, the rate of development is improving. The average I.Q. test score is 100. These children have standard scores around 60. At the end of two years, children in the intervention had standard scores of 78.5. That’s outside the range of what would be considered an intellectual disability.

Q.

How can parents learn more about this intervention?

A.

All the material, the book, curriculum, the measurement tools, are available to the public online, and there is also a manual published by Guilford Press. It’s not simple. Parents require a lot of coaching into how to position themselves so they’ve got children’s attention; how to get children to watch them; how to pull gestures out of the children so the child is communicating; how to choose activities so they have maximal pleasure so the child is motivated. We teach multiple different kinds of skills. Inside one particular play activity, you can get a lot of learning in.

When I first read this I thought, “Well, of course the children do better with individualized interactive teaching, rather than ‘dog and pony show’ style teaching that is pervasive in our educational system.” Probably ALL children would do better with this style education, not just the autistic ones!

But then I thought, “Well, at least they figured it out.” Hopefully more children — both autistic AND not-autistic will be able to benefit from this kind of tailored education.

Interesting findings, in light of the fact that another recent study found that about 1% of all births may have one of the autism spectrum disorders.

Here’s another interesting finding to think about: It’s been proposed that the rate of autism started to rise dramatically since the implementation of the “back to sleep” campaign in the early 90s. Yes, SIDS dropped significantly, but just like any idea with good intentions, there are always unintended consequences.

Here’s the blog post that links to the proposed theory and my response to it on my site:

Over the years there have been many diverse theories concerning the etiogies and treatments for autism. From the refrigorator parents’ cause of the disorder (completely untrue)… And now the most popular cause is genetically predisposed brain disease.

About 10 years ago some suggested using computer techniques to help kids with autism… This was later found to be a complete fraud.

Now reported, above: E. S. D. M.

Let’s wait this one out: with scurpulous well -designed studies to validate this new technique and not use this widely until found to be viable for some… We have been disappointed too many times in the past.

Congratulations Ms Parker-Pope you managed to present this study without mentioning that the ESDM intervention employs principles of Applied Behavior Analysis as set out in the report in the AAP journal Pediatrics :

“(1) ESDM intervention, which is based on developmental and applied behavioral analytic principles”
FROM TPP — I’m not sure what your point is. Does that additional detail matter to the average reader?

As a special ed teacher, I’m having trouble understanding what makes this procedure any different (one iota different) from what has already been going on for years. I can’t tell if it’s the article itself or the self-promotion of the researcher; but I have to say this ‘news’ looks a lot like blatant self-promotion aided and abetted by the reporter. For instance, the researcher’s answer about the difference between the ‘two methods,” is either sophistry or in outright misrepresentation. First of all, there aren’t ‘two methods.’ There are many. But all of them focus on the individual needs of the child. In setting herself up to contrast with some mythical formulaic group setting, the researcher sets up a straw man that she herself can knock down (and boost her book sales).

It sounds like she’s saying the difference between her methods is a) her method is more joyful and b) her reward is natural consequences (give the child the ball rather than, say, a cracker). But no one I know would remove the joy out of the interaction–literally no one. And no one I know would not reward with natural consequences at the very least; of course it may help to give the child an additional reward, but that reward is ALWAYS individualized to what works for the individual child.

Finally, her procedure has on average 3.5 more hours per week with the child, and sounds highly individualized. Of course the IQs will be higher! Nothing remarkable there. At all. Nothing new. At all. Basically, the more money you spend on helping a child with autism – the more active, involved and individualized the attention (individualized is key) – the better the results. It doesn’t take a rocket scientist to figure this out, and we’ve known this for years, as I’ve said. This really sounds like blatant self-promotion backed by gullible reporting.

To Dr. Park
I am not an MD nor do I work with children with autism, although I have worked on and published much on early childhood issues. I agree that with the spike in autism rates, it’s a good thing to look at all possible causes. But the link to “back to sleep” doesn’t seem all that plausible for this reason: many cultures, such as the East Indian, have traditionally put their children to sleep on their backs, and those cultures had lower SIDS rates all along (although they may have had extremely high infant mortality rates from other causes). Those cultures have maintained a similar autism rate to that of the US. Since they have for who knows how long put their babies to sleep on their backs, but didn’t have higher rates of autism, I think this lack of correlation means you may have to look elsewhere.

I certainly commend the efforts of those who are engaged in finding causes of autism that go beyond the disproved relationship with vaccines.

This approach seems somewhat related to floor time, which has had trouble producing numbers, in part because, like this approach it does not have firmly established routines. My memory is that floor time is also not as focused on the very young.
One of the charms to this system is that while the behavioral conditioning to which it is compared is effective in producing very particular outcomes, it does so by concentrating on them to the exclusion of all normal play or interaction. There is effectively only one thing to learn: sit in the chair and say the word. In the Denver approach they learn about balls and their own bodies’ interactions with the world even if they don’t learn the social and vocabulary skills that are targeted.

Well, this pretty much shoots down the definition of IQ, which is that it is a scientifically normed and defined measure of innate intellectual ability or capacity, as opposed to a socially and subjectively contrived measure of acquired and demonstrable thinking skills.

As a father with an autistic child, I strongly concur with the early intervention approach. Our son was diagnosed with “autism like sensory issues” at 16 months by our excellent pediatrician and our son has been in intensive therapy (Occupational, Speech and Physical) since his diagnosis. We have carefully avoided fads, diets and drugs and stayed with the expert advice we were given. From 16 months to 6 years, it was really tough and I did not know if he or us were going to make it. Today, our son is 11 and 1-2 grade levels below in reading, at grade level for math, has a huge (too huge sometimes if you get my meaning) vocabulary and can interact fairly well with others. He still has autistic behaviors and goes to a middle school for autistics, but participates in all other ways with the family. Everyone wants whats best for their autistic children but I strongly recommend staying with the experts. We plan on sending our son (who is the joy of our lives) to college and believe he will have a full and wonderful life!!

#5: People “know” a lot of things. There are all sorts of “common knowledge” out there, “common wisdom” even within subspecialties like special ed. But science doesn’t accept what we “know”–nor should it. Yes, we scientists actually want to test theories, not rely on common wisdom.

I’m surprised that as a special ed teacher you don’t grasp that it’s important not just to note that there is a difference between the two treatment groups, but how GREAT the difference is. Why? Because parents who want school districts to offer programs and time like this need to be able to point to a peer reviewed study to force change, or to get insurance companies to pay for the therapy their kids need. Parents also need some reassurance that the differences can actually be quite significant–they’re not going to take your word for it, nor should they. Naturally the bureaucracies that offer or pay for these therapies also want real evidence, not your intuition. Furthermore, replication is appreciated in science if not by other communities.

Wow, every single time I read an article about someone doing SOMETHING to help our kids with autism, I always read negative comments and I see a lot of skepticals.

Are you people parents of children with an ASD? Or are you providers, therapists?

I just feel like a need to write — Do you want help or not? Parents do want the help and the research, we don’t have all the information that we should have about autism, so when a Doctor or scientist is researching and working on finding answers or a way to help our kids, I would like to see more support for their work.

By the way, you don’t need to answer my post. Or write back disecting every single line I wrote, I an not interested on a reply.

I am very happy that there are people out there trying to figure out a way that might help our children learn.

FROM TPP — Well I’m glad you wrote because I’m surprised and disappointed by the skeptical tone of most responses so far. This researcher is publishing her information for free. The program was tested in a randomized study and published in an important peer reviewed journal. In my experience, parents of children with autism want all the information they can find, and I felt like this particularly piece of research deserved further attention. It seems like there are so many different agendas out there, but I’m interested in the agenda of parents who are trying to find the latest information to help their children. Thanks for your comments.

Has anyone done studies comparing autism rates among different groups of Americans? Is the autism rate for Mennonites, Amish, Mormons, vegetarians, Vegans, Christian Scientists the same? Or is it different.

My theory is that the child is bombarded with so much “stuff” from birth, like forced birth, more vaccinations that its system can handle, environmental toxins, chemicals in fake foods, substitutes for mothers’ milk, constant noise, that he simply must retreat.

Please remember that the IQ SCORE went up. This does not mean that the IQ itself went up. As the autistic child’s language increased, you would expect the child’s IQ score is increase similarly. This happens simply because the majority of IQ tests involve language in some way or another. This study does not increase the actual IQ of the child. It does increase the child’s ability to communicate their cognitive ability. An important feat, but not the same as actually increasing IQ.

This approach is so close to floortime, developed by Stanley Greenspan, that I read the entire interview in vain to try to discern a difference. Maybe it is different, but the article doesn’t address this, instead repeating the researcher’s self-serving assertion that this is the first play-based intervention. That is simply not true, as those of us with autistic children know. The researcher seems to refer to ABA as if it represents the entire universe of autism interventions before she came along. But those of us who live in autism world know that there has been a raging debate for years about the various methods of intervening, including play-based methods. And floortime is used with toddlers and even infants.

By not acknowledging any of this and by completely accepting the researcher’s assertions without skepticism or even the most basic research, this interview represents poor reporting and presents misinformation. Its not that I’m such a floortime advocate (though it helped my son tremendously) its just that I hate to such such an obvious omission.

I have been working with autistic children for more than 36 years. The present results do look impressive and would make may in the field cheer. I don’t doubt the treatment group improved. But closer scrutiny would make Diana’s comment pertinent. Here are my issues:

1. The ‘method’ is politically correct as it focuses heavily on the ‘fun’ part, but is situation-specific and non-replicable. What if the child has no interest in the ball, as the reporter rightly observed? If the goal is: you must teach the utterance and meaning of ‘ball’, or any other words the therapist deems functional, then this approach is haphazard and not replicable. That is, treatment ontegrity cannot be maintained.

2. The treatment is labor intensive and training intensive. Parents can’t be expected to carry it out accurately. Again, a treatment integrity problem.

3. 3.5 hrs more a week of one-on-one makes a lot of difference. The groups are not equal in quantity of therapy.

4. How do you accurately measure IQ’s of children younger than six?

5. Many young children labeled autistic, in my analysis, are nonsocial due to poor language understanding and usage. A more accurate label to aid traetment focus is language delay or deficiency. I have treated young children that have been diagnosed as autistic by research programs purely along training functional language. As they improved, they are no longer ‘autistic’.

actually, it DOES increase IQ. Whether it increases every aspect of functional INTELLIGENCE is another matter. And di, NOBODY except the “bell curve” racist nutcakes would assert that all of IQ is “innate”. Nonsense. nature and nurture interact throughout development and are not really separable. That does NOT, however, make every assessment measure “subjective”. If a measure reliably corrrelates with ability to function adaptively, it is measuring something useful. Doesn’t have a thing to do with how or when people acquire those abilities or are helped, as in this case, to develop them and express them.

One needs to be cautious in interpreting these results. One problem is that the children’s progress was monitored by the same University of Washington researchers that were providing the therapy. It would be extremely easy for the therapists in the new treatment group to “teach to the test”, knowingly or unknowingly. In other words, this does not appear to be a true, double-blind scientific study. The sample size is better than many previous studies, but still nothing like the broad, longitudinal study one would want to see before contemplating a treatment regimen of this scope and cost. It would also be more helpful, in my opinion, to have control groups receiving nothing more than a regular nursery school program, and/or no treatment program at all.

From an epistemological view, it is also worrisome that Ms. Dawson is the chief science officer for Autism Speaks, and has simultaneously created a book and teaching materials just as the study is being publicized. Science and enterprise should ideally be somewhat separated, for obvious reasons. Finally, one should take into account that most health insurance does not cover the kind of treatments described here, but that if it did (based on the sort of unequivocal diagnoses and treatment results presented here), an enormous amount of funding would be diverted to such therapies.

Happy that children with autism are finding more success? Thrilled at more early intervention? Delighted that current-day parents of toddlers diagnosed with autism don’t have to relive the horrors of the treatments (or lack thereof) of many generations that came before them? Of course. A “new” approach? Not even close. As part of his “verbal behavior” program–a form of applied behavior analysis using concepts from BF Skinner’s book by that name, and effective teaching techniques such as keeping demands and reinforcement in balance, and making the teaching environment an improving set of conditions–our 17-year old son with autism has been receiving “natural environment training” for nearly ten years, along with hundreds and possibly thousands of other children with autism (for but one example, see, e.g., http://www.drcarbone.net/videoPopup.aspx?video=2). Finding a way to help your child is hard enough on a parent; trumpeting an allegedly new discovery without sufficient research on where the latest study fits in the literature will (if the past is any guide) only cause a stampede of upset parents (for an approach that may be more accessible to them but with a different label. The focus should be on the science and the technique, not on who developed the “method”.
It also wasn’t clear from the article whether this is a program in which formalized learning is completely absent, but if this is in fact the case, it also has to deal with the extremely difficult problem of how to teach language and skills that are not present in teachable form in the child’s every day environment, without having either some formal “at the table” time.
Finally, the demonization of temporarily reinforcing kids with “m&ms, juice and crackers” ignores the fact that even these won’t work if the child doesn’t truly desire them, and what is reinforcing ALWAYS has to start with the child likes or is taught to like, not what the teacher thinks the child likes. Our son’s strongest reinforcer at the moment is when he has other adults play act while he directs a particular scene from “Bedknobs and Broomsticks”. And before you think that’s a little weird, take a minute and think what ALL of us actually find reinforcing in our every day lives.
Actually, the idea that you have to start from what is interesting is probably as old as teaching itself. The real lesson is that in teaching children with autism, this lesson shouldn’t be forgotten.

As both a parent of two children on the spectrum, and a behavioral scientist, I can only applaud these findings. It’s important to note that the evidence base for very early intervention (< 2 years old) is very sparse, and this research was very carefully undertaken, and is currently being followed by a more rigorous controlled trial. Accumulating evidence permits more effective lobbying for access to needed interventions.
I’m not concerned about whether this intervention shares features with ABA or ESDM or Floortime– in fact, I assume there will be overlap across approaches. Finding evidence for one intervention does not preclude accumulating evidence for other intervention approaches. In fact, it’s likely that more than one approach to intervening will be effective, and that some approaches will “fit” particular children and their families better than others (e.g., some may be drawn to floortime, others to ABA, others to ESDM). It’s also likely that what “works” in each intervention may overlap– for example– the central importance of finding what motivates each child (often a moving target!)
Demonstrating efficacy of an intervention with children at such young ages is no easy task, and I’m so happy that the National Institutes of Science are funding research on ESDM and Floortime, along with other promising early interventions. I hope that the result of this research is greater access to an array of effective interventions for families and children who might find benefit.

I empathize with the want for effective programming for children with autism spectrum disorder and I applaud those who work toward creating and finding that programming. That being said, I don’t know how any program can be judged effective or productive when the proof is based in part on the IQ test results of 18-month-old children. I’m not aware of any truly reliable IQ assessments for this age group whose members, “normal’ or not, have very limited language and reasoning abilities – two of the main skill areas on which IQ tests are typically based. At the risk of sending skeptical, might the difference in the pre and post IQ test results in this study be explained by better measurement ability as a child gets older?

Another good possibility is though it is not mainstream to use homeopathy. The author of this article had an autistic son, who is cured and a collage student.http://tinyurl.com/ykhg2su
She wrote a book about it:
Impossible Cure: The Promise of Homeopathy by Amy L. Lansky